3/3 Question 1-3 of 23

Theme: Skin disease

A. Squamous cell carcinoma

B. Bowens disease
C. Actinic keratosis
D. Basal cell carcinoma
E. Malignant melanoma
F. Keratoacanthoma
G. Apthous ulcer
H. Pyogenic granuloma

Please select the most likely underlying diagnosis for each of the following skin lesions. Each option may be
used once, more than once or not at all.

1. A 53 year old man presents with a nodule on his chin. He is concerned because it has grown extremely
rapidly over the course of the preceding week. On examination he has a swollen, red, dome shaped
lesion with a central defect that contains a keratinous type material.

Keratoacanthoma

Theme from April 2013 Exam

Keratoacanthomas are characterised by a rapid growth phase. This may mimic amelanotic melanoma
(although such rapid growth is rare even in these lesions). The keratin core is the clue as to the true
nature of the lesion.

2. A 68 year old farmer presents with a skin lesion on his forehead. It has been present for the past 6
months and has grown slightly in size during that time. On examination he has an ulcerated lesion with
pearly white raised edges that measures 2cm in diameter.

Basal cell carcinoma

The raised pearly edges in an ulcerated lesion at a sun exposed site makes BCC most likely.

3. A 34 year old gardener presents with a lesion affecting the dorsum of his right hand. It has been
present for the past 10 days and occurred after he had been pruning rose bushes. On examination he
has a raised ulcerated lesion which bleeds easily on contact.

Pyogenic granuloma
 Trauma is a common precipitant of pyogenic granuloma and contact bleeding and ulceration are
common.

Skin disorders in surgery- malignancy and related lesions

Non melanoma skin cancer (BCC and SCC) are some of the commonest types of human malignancy. Up to
80% of these are BCC's with approximately 20% comprising SCC's. The incidence of NMSC's increases with
age and whilst there is a female preponderance in those under 40 years of age, in latter life the sex incidence is
roughly equal.
The vast majority of NMSC's are related to UV light exposure. For SCC's the major pattern is is chronic long
term exposure. For BCC's, the pattern of sporadic exposure with episodes of burning is more important. Organ
transplant recipients have a markedly increased incidence of SCC, risk factors include length of
immunosuppression, ethnic origin and associated sunlight exposure. Human papilloma virus DNA is found in
the majority of transplant recipient SCC's. In addition to this increased risk, transplant recipients are also more
likely to develop locoregional recurrences following treatment.

Actinic keratosis and SCC

Actinic keratosis is viewed as a premalignant lesion because there are atypical keratinocytes present in the
epidermis. In a person with 7 actinic keratosis the risks of subsequent SCC is of the order of 10% at 10 years.
The primary lesion is a rough eryhtematous papule with a white to yellow scale. Lesions are typically clustered
at sites of chronic sun exposure.

Squamous cell carcinoma in situ

Also known as Bowens disease the commonest presentation of in situ SCC is with an erythematous scaling
patch or elevated plaque arising on sun exposed skin in an elderly patient. Lesions may arise de novo or from
pre-existing actinic keratosis.
Pathologically there is full thickness atypia of dermal keratinocytes over a broad zone. Nuclear pleomorphism,
apoptosis and abnormal mitoses are all seen.

Invasive SCC
The commonest clinical presentation of SCC is with an erythematous keratotic papule or nodule on a
background of sun exposure. Ulceration may occur and both exophytic and endophytic areas may be seen.
Regional lymphadenopathy may be present.
Pathologically there is downward proliferation of malignant cells and invasion of the basement membrane.
Poorly differentiated lesions may show perineural invasion and require immunohistochemistry with S100 to
distinguish them from melanomas (which stain strongly positive with this marker).

Basal cell carcinoma

Nodular BCC Commonest variant (60%)
Raised translucent papule
Usually affect the face
Large nodular BCC's are locally destructive
Superficial BCC Usually appears as superficial erthematous macule affecting the trunk
Younger age at presentation (mean 57)
May show areas of spontaneous regression
Horizontal growth patter predominates
High recurrence rate (due to sub clinical lateral spread)
Morpheaform BCC Macroscopically resembles flat, slightly atrophic lesion or plaque without well
defined borders
Tumour has sub clinical lateral spread which increases recurrence rates
Cystic BCC Often have clear or blue - grey appearance
Cystic degeneration may not be clinically obvious and tumour may resemble
nodular BCC
Basosquamous Atypical BCC
carcinoma Basaloid histological BCC features with eosinophillic squamoid features of SCC
Biologically more aggressive and are more locally destructive
Rare lesion accounts for 1% of all non melanoma skin cancers
Metastatic disease may occur in 9-10% of cases and resemble an SCC

Keratoacanthoma
Dome shaped erythematous lesions that develop over a period of days and grow rapidly. They often contain a
central pit of keratin. They then begin to necrose and slough off. They are generally benign lesions although
some do view them as precursors of malignancy. They may be treated by curettage and cautery. If there is
diagnostic doubt (they can mimic malignancy) then formal excision biopsy is warranted.

Pyogenic granuloma
These present as friable overgrowths of granulation at sites of minor trauma. They may be ulcerated and
bleeding on contact is common. They may be treated with curretage and cautery, formal excision may be used if
there is diagnostic doubt.

1/3 Question 4-6 of 23

Theme: Skin disorders

A. Basal cell carcinoma

B. Dermatofibroma
C. Pilar cyst
D. Epidermoid cyst
E. Spitz naevus
F. Seborrhoeic keratosis
G. Atypical naevus
H. Capillary cavernous haemangioma

Please select the most likely underlying nature of the skin lesion described. Each option may be used once,
more than once or not at all.

4. A 70 year old lady presents with a number of skin lesions that she describes as unsightly. On
examination she has a number of raised lesions with a greasy surface located over her trunk. Apart
from having a greasy surface the the lesions also seem to have scattered keratin plugs located within
them.

Seborrhoeic keratosis

Theme from September 2012 Exam

Seborrhoeic keratosis may have a number of appearances. However, the scaly, thick, greasy surface
with scattered keratin plugs makes this the most likely diagnosis.

5. A 28 year old female presents with a small nodule located on the back of her neck. It is excised for
cosmetic reasons and the histology report states that the lesion consists of a sebum filled lesion
surrounded by the outer root sheath of a hair follicle.

You answered Epidermoid cyst

The correct answer is Pilar cyst

Pilar cysts may contain foul smelling cheesy material and are surrounded by the outer part of a hair
follicle. Because of their histological appearances they are more correctly termed pilar cysts than
sebaceous cysts.

6. A 21 year old lady presents with a nodule on the posterior aspect of her right calf. It has been present
at the site for the past 6 months and occurred at the site of a previous insect bite. Although the nodule
appears small, on palpation it appears to be nearly twice the size it appears on examination. The
overlying skin is faintly pigmented.

You answered Spitz naevus

The correct answer is Dermatofibroma

Dermatofibromas may be pigmented and are often larger than they appear. They frequently occur at
sites of previous trauma.

Benign skin diseases

Seborrhoeic keratosis
 • Most commonly arise in patients over the age of 50 years, often idiopathic
• Equal sex incidence and prevalence
• Usually multiple lesions over face and trunk
• Flat, raised, filiform and pedunculated subtypes are recognised
• Variable colours and surface may have greasy scale overlying it
• Treatment options consist of leaving alone or simple shave excision

Melanocytic naevi
Congenital melanocytic • Typically appear at, or soon after, birth
naevi • Usually greater than 1cm diameter
• Increased risk of malignant transformation (increased risk greatest for large
lesions)

Junctional melanocytic • Circular macules

naevi • May have heterogeneous colour even within same lesion
• Most naevi of the palms, soles and mucous membranes are of this type

Compound naevi • Domed pigmented nodules up to 1cm in diameter

• Arise from junctional naevi, usually have uniform colour and are smooth

Spitz naevus • Usually develop over a few months in children

• May be pink or red in colour, most common on face and legs
• May grow up to 1cm and growth can be rapid, this usually results in
excision

Atypical naevus • Atypical melanocytic naevi that may be autosomally dominantly inherited
syndrome • Some individuals are at increased risk of melanoma (usually have mutations
of CDKN2A gene

- Many people with atypical naevus syndrome AND a parent sibling with melanoma
will develop melanoma

Epidermoid cysts

• Common and affect face and trunk

• They have a central punctum, they may contain small quantities of sebum
• The cyst lining is either normal epidermis (epidermoid cyst) or outer root sheath of hair follicle (pilar
cyst)

Dermatofibroma

• Solitary dermal nodules

 • Usually affect extremities of young adults
• Lesions feel larger than they appear visually
• Histologically they consist of proliferating fibroblasts merging with sparsely cellular dermal tissues

Painful skin lesions

• Eccrine spiradenoma
• Neuroma
• Glomus tumour
• Leimyoma
• Angiolipoma
• Neurofibroma (rarely painful) and dermatofibroma (rarely painful)

1/3 Question 7-9 of 23

Theme: Skin lesion diagnosis

A. Pyogenic granuloma
B. Amelanotic melanoma
C. Dermatitis herpetiformis
D. Scabies
E. Basal cell carcinoma
F. Squamous cell carcinoma
G. Keratoacanthoma

Please select the most likely underlying diagnosis for the scenario given. Each option may be used once, more
than once or not at all.

7. A 72 year old man presents with a large nodule on his face. It is friable. There is no regional
lymphadenopathy. He is lost to follow up and re-attends several months later. On this occasion the
lesion has been noted to resolve with scarring.

You answered Dermatitis herpetiformis

The correct answer is Keratoacanthoma

Keratoacanthomas may reach a considerable size prior to sloughing off and scarring.

8. A 22 year old girl is troubled by intensely itchy crops of blisters on her arms and legs. On examination
she is malnourished and she has papulovesicular eruptions over her elbows and knees.
 You answered Scabies

The correct answer is Dermatitis herpetiformis

Dermatitis herpetiformis is seen in association with coeliac disease.

9. A 30 year old man cuts the corner of his lip whilst shaving. Over the next few days a large purplish
lesion appears at the site which bleeds on contact.

Pyogenic granuloma

Pyogenic granulomas often appear at sites of trauma.

Skin Diseases

Skin lesions may be referred for surgical assessment, but more commonly will come via a dermatologist for
definitive surgical management.

Skin malignancies include basal cell carcinoma, squamous cell carcinoma and malignant melanoma.

Basal Cell Carcinoma

• Most common form of skin cancer.

• Commonly occur on sun exposed sites apart from the ear.
• Sub types include nodular, morphoeic, superficial and pigmented.
• Typically slow growing with low metastatic potential.
• Standard surgical excision, topical chemotherapy and radiotherapy are all successful.
• As a minimum a diagnostic punch biopsy should be taken if treatment other than standard surgical
excision is planned.

Squamous Cell Carcinoma

• Again related to sun exposure.

• May arise in pre - existing solar keratoses.
• May metastasise if left.
• Immunosupression (e.g. Following transplant), increases risk.
• Wide local excision is the treatment of choice and where a diagnostic excision biopsy has demonstrated
SCC, repeat surgery to gain adequate margins may be required.
Malignant Melanoma
The main diagnostic features (major criteria): Secondary features (minor criteria)

• Change in size • Diameter >6mm

• Change in shape • Inflammation
• Change in colour • Oozing or bleeding
• Altered sensation

Treatment

• Suspicious lesions should undergo excision biopsy. The lesion should be removed in completely as
incision biopsy can make subsequent histopathological assessment difficult.
• Once the diagnosis is confirmed the pathology report should be reviewed to determine whether further
re-exicision of margins is required (see below):

Margins of excision-Related to Breslow thickness

Lesions 0-1mm thick 1cm
Lesions 1-2mm thick 1- 2cm (Depending upon site and pathological features)
Lesions 2-4mm thick 2-3 cm (Depending upon site and pathological features)
Lesions >4 mm thick 3cm
Marsden J et al Revised UK guidelines for management of Melanoma. Br J Dermatol 2010 163:238-256.

Further treatments such as sentinel lymph node mapping, isolated limb perfusion and block dissection of
regional lymph node groups should be selectively applied.

Kaposi Sarcoma

• Tumour of vascular and lymphatic endothelium.

• Purple cutaneous nodules.
• Associated with immunosupression.
• Classical form affects elderly males and is slow growing.
• Immunosupression form is much more aggressive and tends to affect those with HIV related disease.

Non malignant skin disease

Dermatitis Herpetiformis

• Chronic itchy clusters of blisters.

• Linked to underlying gluten enteropathy (coeliac disease).
Dermatofibroma

• Benign lesion.
• Firm elevated nodules.
• Usually history of trauma.
• Lesion consists of histiocytes, blood vessels and fibrotic changes.

Pyogenic granuloma

• Overgrowth of blood vessels.

• Red nodules,
• Usually follow trauma.
• May mimic amelanotic melanoma.

Acanthosis nigricans

• Brown to black, poorly defined, velvety hyperpigmentation of the skin.

• Usually found in body folds such as the posterior and lateral folds of the neck, the axilla, groin,
umbilicus, forehead, and other areas.
• The most common cause of acanthosis nigricans is insulin resistance, which leads to increased
circulating insulin levels. Insulin spillover into the skin results in its abnormal increase in growth
(hyperplasia of the skin).
• In the context of a malignant disease, acanthosis nigricans is a paraneoplastic syndrome and is then
commonly referred to as acanthosis nigricans maligna. Involvement of mucous membranes is rare and
suggests a coexisting malignant condition

Question 10 of 23
A 22 year old man presents with an infected sebaceous cyst. The cyst itself is swollen, discharging pus and has
some surrounding erythema. What is the most appropriate treatment?

A. Excision of the cyst of closure of the defect with interrupted 3/0 silk

B. Excision of the cyst and closure of the defect with subcuticular 4/0
undyed nylon

C. Incision and drainage with excision of the cyst wall and packing of
the defect

D. Incision and drainage with conservation of the cyst wall and packing
of the defect

E. Administration of oral co-amoxyclav and definitive surgery once the

infection has cleared
Similar theme in January 2013 Exam
The correct treatment for an infected sebaceous cyst is incision and drainage with removal of the cyst wall.
Conservation of the cyst wall will invariably lead to recurrence. Under no circumstances should an infected
wound like this be primarily closed. The administration of antibiotics without drainage of sepsis is futile.

Sebaceous cysts

• Originate from sebaceous glands and contain sebum.

• Location: anywhere but most common scalp, ears, back, face, and upper arm (not palms of the hands
and soles of the feet).
• They will typically contain a punctum.
• Excision of the cyst wall needs to be complete to prevent recurrence.
• A Cock's 'Peculiar' Tumour is a suppurating and ulcerated sebaceous cyst. It may resemble a squamous
cell carcinoma- hence its name.

1/3 Question 11-13 of 23

Theme: Management of skin lesions

A. Excision biopsy
B. Excision with 0.5 cm margin
C. Excision with 2 cm margin
D. Shave biopsy and cautery
E. Punch biopsy
F. Excision and full thickness skin graft
G. Discharge

For each skin lesion please select the most appropriate management option. Each option may be used once,
more than once or not at all.

11. A 22 year old women presents with a newly pigmented lesion on her right shin, it has regular borders
and normal appearing dermal appendages, however she reports a recent increase in size.

You answered Excision with 0.5 cm margin

The correct answer is Excision biopsy

Likely to be a benign pigmented naevus, radical excision therefore not warranted.

12. A 58 year old lady presents with changes that are suspicious of lichen sclerosis of the perineum.
 Punch biopsy

This will generate sufficient material for histological assessment.

13. A 73 year old man presents with a 1.5cm ulcerated basal cell carcinoma on his back.

You answered Excision with 2 cm margin

The correct answer is Excision with 0.5 cm margin

A small lesion such as this is adequately treated by local excision. The British Association of
Dermatology guidelines suggest that excision of conventional BCC (<2cm) with margins of 3-5mm
have locoregional control rates of 85%. Morpoeic lesions have higher local recurrence rates.

Skin Diseases

Skin lesions may be referred for surgical assessment, but more commonly will come via a dermatologist for
definitive surgical management.

Skin malignancies include basal cell carcinoma, squamous cell carcinoma and malignant melanoma.

Basal Cell Carcinoma

• Most common form of skin cancer.

• Commonly occur on sun exposed sites apart from the ear.
• Sub types include nodular, morphoeic, superficial and pigmented.
• Typically slow growing with low metastatic potential.
• Standard surgical excision, topical chemotherapy and radiotherapy are all successful.
• As a minimum a diagnostic punch biopsy should be taken if treatment other than standard surgical
excision is planned.

Squamous Cell Carcinoma

• Again related to sun exposure.

• May arise in pre - existing solar keratoses.
• May metastasise if left.
• Immunosupression (e.g. Following transplant), increases risk.
• Wide local excision is the treatment of choice and where a diagnostic excision biopsy has demonstrated
SCC, repeat surgery to gain adequate margins may be required.
Malignant Melanoma
The main diagnostic features (major criteria): Secondary features (minor criteria)

• Change in size • Diameter >6mm

• Change in shape • Inflammation
• Change in colour • Oozing or bleeding
• Altered sensation

Treatment

• Suspicious lesions should undergo excision biopsy. The lesion should be removed in completely as
incision biopsy can make subsequent histopathological assessment difficult.
• Once the diagnosis is confirmed the pathology report should be reviewed to determine whether further
re-exicision of margins is required (see below):

Margins of excision-Related to Breslow thickness

Lesions 0-1mm thick 1cm
Lesions 1-2mm thick 1- 2cm (Depending upon site and pathological features)
Lesions 2-4mm thick 2-3 cm (Depending upon site and pathological features)
Lesions >4 mm thick 3cm
Marsden J et al Revised UK guidelines for management of Melanoma. Br J Dermatol 2010 163:238-256.

Further treatments such as sentinel lymph node mapping, isolated limb perfusion and block dissection of
regional lymph node groups should be selectively applied.

Kaposi Sarcoma

• Tumour of vascular and lymphatic endothelium.

• Purple cutaneous nodules.
• Associated with immunosupression.
• Classical form affects elderly males and is slow growing.
• Immunosupression form is much more aggressive and tends to affect those with HIV related disease.

Non malignant skin disease

Dermatitis Herpetiformis

• Chronic itchy clusters of blisters.

• Linked to underlying gluten enteropathy (coeliac disease).
Dermatofibroma

• Benign lesion.
• Firm elevated nodules.
• Usually history of trauma.
• Lesion consists of histiocytes, blood vessels and fibrotic changes.

Pyogenic granuloma

• Overgrowth of blood vessels.

• Red nodules,
• Usually follow trauma.
• May mimic amelanotic melanoma.

Acanthosis nigricans

• Brown to black, poorly defined, velvety hyperpigmentation of the skin.

• Usually found in body folds such as the posterior and lateral folds of the neck, the axilla, groin,
umbilicus, forehead, and other areas.
• The most common cause of acanthosis nigricans is insulin resistance, which leads to increased
circulating insulin levels. Insulin spillover into the skin results in its abnormal increase in growth
(hyperplasia of the skin).
• In the context of a malignant disease, acanthosis nigricans is a paraneoplastic syndrome and is then
commonly referred to as acanthosis nigricans maligna. Involvement of mucous membranes is rare and
suggests a coexisting malignant condition

2/3 Question 14-16 of 23

Theme: Dermatological manifestations of disease

A. Pyoderma gangrenosum
B. Erythroderma
C. Dermatitis herpetiformis
D. Acanthosis nigricans
E. Multiple lipomata
F. Multiple neurofibromata
G. Multiple telangectasia
H. None of the above

Please select the skin disease associated with the condition described. Each option may be used once, more than
once or not at all.
 14. A 22 year old man is investigated for weight loss. A duodenal biopsy taken as part of his
investigations shows total villous atrophy and lymphocytic infiltrate. He has a skin lesion that has
small itchy papules.

You answered Erythroderma

The correct answer is Dermatitis herpetiformis

Theme from September 2012 Exam

The patient has coeliac disease and this is associated with dermatitis herpetiformis.

15. A 72 year old man is investigated for weight loss. On examination he is deeply jaundiced and
cachectic. He also has a dark velvety lesion coating his tongue.

Acanthosis nigricans

Acanthosis nigricans may be associated with GI malignancies such as gastric and pancreatic cancer.

16. A lesion that may occur in a 32 year old man with long standing Crohns disease.

Pyoderma gangrenosum

Pyoderma gangrenosum may occur in Crohns disease.

Question 17 of 23
Which of the following statements relating to sebaceous cysts is false?

A. When infected are also known as Cocks peculiar tumour

B. Typically contain pus

C. Are usually associated with a central punctum

D. Most commonly occur on the scalp

E. They will typically have a cyst wall

Sebaceous cysts usually contain sebum, pus is only present in infected sebaceous cysts which should then be
treated by surgical incision and drainage.

Question 18 of 23
Which of the following statements relating to Keloid scars is untrue?

A. They have a predilection for sternal , mandibular and deltiod area

wounds

B. They are confined to the margins of the original injury

C. They often recur following excision

D. May occur even after superficial injury

E. They may be treated by injection of triamcinolone

Hypertrophic scars remain confined to the
wound edges.

Keloids (by definition) will tend to extend beyond the margins of the wound and in wounds of any depth.

Wound healing

Surgical wounds are either incisional or excisional and either clean, clean contaminated or dirty. Although the
stages of wound healing are broadly similar their contributions will vary according to the wound type.

The main stages of wound healing include:

Haemostasis

• Vasospasm in adjacent vessels, platelet plug formation and generation of fibrin rich clot.

Inflammation

• Neutrophils migrate into wound (function impaired in diabetes).

• Growth factors released, including basic fibroblast growth factor and vascular endothelial growth factor.
• Fibroblasts replicate within the adjacent matrix and migrate into wound.
• Macrophages and fibroblasts couple matrix regeneration and clot substitution.

Regeneration

• Platelet derived growth factor and transformation growth factors stimulate fibroblasts and epithelial
cells.
• Fibroblasts produce a collagen network.
• Angiogenesis occurs and wound resembles granulation tissue.

Remodeling

• Longest phase of the healing process and may last up to one year (or longer).
• During this phase fibroblasts become differentiated (myofibroblasts) and these facilitate wound
contraction.
 • Collagen fibres are remodeled.
• Microvessels regress leaving a pale scar.

The above description represents an idealised scenario. A number of diseases may distort this process. It is
obvious that one of the key events is the establishing well vascularised tissue. At a local level angiogenesis
occurs, but if arterial inflow and venous return are compromised then healing may be impaired, or simply nor
occur at all. The results of vascular compromise are all too evidence in those with peripheral vascular disease or
those poorly constructed bowel anastomoses.

Conditions such as jaundice will impair fibroblast synthetic function and overall immunity with a detrimental
effect in most parts of healing.

Problems with scars:

Hypertrophic scars
Excessive amounts of collagen within a scar. Nodules may be present histologically containing randomly
arranged fibrils within and parallel fibres on the surface. The tissue itself is confined to the extent of the wound
itself and is usually the result of a full thickness dermal injury. They may go on to develop contractures.

Image of hypertrophic scarring. Note that it remains confined to the boundaries of the original wound:

Image sourced from Wikipedia

Keloid scars
Excessive amounts of collagen within a scar. Typically a keloid scar will pass beyond the boundaries of the
original injury. They do not contain nodules and may occur following even trivial injury. They do not regress
over time and may recur following removal.

Image of a keloid scar. Note the extension beyond the boundaries of the original incision:
 Image sourced from Wikipedia

Drugs which impair wound healing:

• Non steroidal anti inflammatory drugs

• Steroids
• Immunosupressive agents
• Anti neoplastic drugs

Closure
Delayed primary closure is the anatomically precise closure that is delayed for a few days but before
granulation tissue becomes macroscopically evident.

Secondary closure refers to either spontaneous closure or to surgical closure after granulation tissue has formed.

Question 20 of 23
A 29 year old man presents with a lump in his scalp. It is located approximately 4cm superior to the external
occipital protuberance. It feels smooth and slightly fluctuant and has a centrally located small epithelial defect.
What is the most likely underlying diagnosis?

A. Cocks peculiar tumour

B. Dermoid cyst

C. Sebaceous cyst

D. Merkel cell tumour

E. Seborrhoeic wart

Sebaceous cysts are most frequently located in the scalp and have an associated central punctum. They may
become infected and develop superficial ulceration in which case they are known as "Cocks Peculiar Tumour".
The presence of a punctum is highly suggestive of a sebaceous cyst and are not typically found in the other
lesions described.

3/3 Question 21-23 of 23

Theme: Management of skin diseases

A. Excision biopsy
B. Excision with 1 cm margin
C. Excision with 5 cm margin
D. Shave biopsy and cautery
E. Punch biopsy
F. Excision and full thickness skin graft
G. Discharge

For each scenario please select the most appropriate management option. Each option may be used once, more
than once or not at all.

21. A 89 year old women presents with long standing seborrhoeic warts of her abdominal wall , they
have caused troublesome itching.

Shave biopsy and cautery

These lesions are often extensive and superficial. Shave excision will suffice, material must be sent
for histology.

22. A 22 year old man has an excision biopsy of a pigmented lesion from his back, histology shows a
1mm depth nodular melanoma, all resection margins are clear of tumour and the nearest is 0.5cm.

Excision with 1 cm margin

This man will require re-excision of margins so that a 1cm margin around the lesion is achieved. This
can usually be achieved without skin grafting.

23. A 73 year old lady presents to the breast clinic with a weeping crusty skin lesion of the left nipple.
There are no masses to feel in the breast itself and imaging is normal.

Punch biopsy

This is likely to represent Pagets disease of the nipple and is best diagnosed on punch biopsy.